Tricare Users Won't Be Able to Switch Plans During Pregnancy

Maj. Lena Fabian (left), staff midwife at William Beaumont Army Medical Center, places a wireless monitoring system on Capt. Merry Fontenot, a staff midwife 36 weeks into her pregnancy on April 21, 2017. Starting in 2019, pregnancy will no longer be a qualifying life event to change Tricare plans. Marcy Sanchez/Army
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Military.com21 Feb 2018By Amy Bushatz

Starting in 2019, Tricare users will no longer be able to switch between coverage plans at will or only because of a pregnancy, according to new rules issued by the agency late last year.

Currently, active-duty military families can at any time switch members of their household from Tricare Prime to Tricare Select, previously known as Tricare Standard, or vice versa. Retiree families who qualify for Tricare Prime are also able to switch at any time. Once users make the swap, they often are locked into the new plan for a year.

However, a series of changes ordered by Congress in 2016 include a requirement that families who want to move plans do so during an "open enrollment" period each year or within a 90-day window after experiencing a "qualifying life event" (QLE).

What is included on that QLE list was not defined in the legislation, and development of the list was left to Tricare officials. Military family advocates last year raised an alarm when a not-yet-finalized QLE list did not include pregnancy.

Female Tricare users often choose to switch plans as a result of a pregnancy in an effort to find care that better fits their needs or schedule, advocates said. For example, some pregnant women may want to see the same provider at every appointment, an option is not always offered at military hospitals. Others may want to deliver at a civilian hospital closer to their home or at a birthing center instead of a hospital. Still others may currently be seen off base, but want to be seen in the on-base hospital for the duration of their pregnancy.

The QLE list, however, does not include pregnancy as a qualifying reason to switch plans.

That means pregnant women will be locked into their plans unless their pregnancy happens to correspond with a separate QLE, such as a relocation, or the annual late fall open enrollment period.

Tricare officials have said their QLE list is meant to reflect the rules used by commercial health insurance plans, which regularly utilize QLE systems.

But leaving "pregnancy" off the Tricare list ignores the military community's special needs or considerations. And commercial plans don't leave women with extremely limited care options the way Tricare does, advocates said.

For example, said Karen Ruedisueli, a government relations deputy director at the National Military Family Association (NMFA), if a woman on Tricare Prime doesn't want to use a military hospital provider for care, she may have no fully covered recourse. But a woman locked into a specific a commercial system could likely still pick a different doctor even within her same coverage plan.

"For this particular type of care, you should be able to say, 'I want my care somewhere else,' " she said. "I'm not aware of another commercial plan where if you're unhappy with care or the hospital where you are, you are stuck."

Ruedisueli said her organization is hoping Tricare officials will change their minds about the QLE exclusion before the rule goes into effect in 2019.